Prehospital Identification of Large Vessel Occlusions Using Modified National Institutes of Health Stroke Scale: A Pilot Study.

William D Mulkerin,Ian P Brown,Michael A Kohn,Prasanthi Govindarajan,Megan D Corry,Ilanit Spokoyny,Matthew J R Nudelman,Brandon Lima,Jonathan T Francisco,Kian Niknam

doi:10.3389/fneur.2021.643356

Abstract

Stroke identification is a key step in acute ischemic stroke management. Our objectives were to prospectively examine the agreement between prehospital and hospital Modified National Institutes of Health Stroke Scale (mNIHSS) assessments as well as assess the prehospital performance characteristics of the mNIHSS for identification of large vessel occlusion strokes.Method: In this prospective cohort study conducted over a 20-month period (11/2016–6/2018), we trained 40 prehospital providers (paramedics) in Emergency Neurological Life Support (ENLS) curriculum and in mNIHSS. English-speaking patients aged 18 and above transported for an acute neurological deficit were included. Using unique identifiers, we linked the prehospital assessment records to the hospital record. We calculated the agreement between prehospital and hospital mNIHSS scores using the Bland-Altman analysis and the sensitivity and specificity of the prehospital mNIHSS.Results: Of the 31 patients, the mean difference (prehospital mNIHSS—hospital mNIHSS) was 2.4, 95% limits of agreement (−5.2 to 10.0); 10 patients (32%) met our a priori imaging definition of large vessel occlusion and the sensitivity of mNIHSS ≥ 8 was 6/10 or 0.60 (95% CI: 0.26–0.88) and the specificity was 13/21 or 0.62 (95% CI: 0.38–0.82), respectively.Conclusions: We were able to train prehospital providers to use the prehospital mNIHSS. Prehospital and hospital mNIHSS had a reasonable level of agreement and and the scale was able to predict large vessel occlusions with moderate sensitivity.

Highlights

Stroke affects 800,000 people in the US annually [1] and treatment is time-dependent
The National Highway Traffic and Safety Administration (NHTSA) in the United States has set forth education of paramedics as one of the priority areas and the objectives of their education agenda include development of a national curriculum, collaboration between academia and prehospital programs, and recognition of prehospital provider education as an academic achievement [13]
We trained 40 paramedics and patients were enrolled prospectively by 17 paramedics who were assigned to the ambulance transport during the study period

Summary

Introduction

Stroke affects 800,000 people in the US annually [1] and treatment is time-dependent. The National Highway Traffic and Safety Administration (NHTSA) in the United States has set forth education of paramedics as one of the priority areas and the objectives of their education agenda include development of a national curriculum, collaboration between academia and prehospital programs, and recognition of prehospital provider education as an academic achievement [13]. To implement these objectives for stroke, one of our investigators (MC) partnered with stroke neurologists to create the ENLS (Emergency Neurological Life Support) curriculum for prehospital care, a standardized curriculum on stroke for prehospital providers. These protocols offer a multidisciplinary approach that promotes interprofessional training and collaborative practice between prehospital EMS providers, nurses, and physicians [14]

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